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NHS 70 Interview: King’s College Hospital

Feature: Healthcare Management

As part of July’s NHS 70 anniversary celebrations, Health Business will be publishing a number of interviews with those working within and for our health service. Here, we pose some questions to Ian Smith, chair of King’s College Hospital NHS Foundation Trust

Now is the perfect opportunity to celebrate the achievements of our health service, but also to analyse the array of opportunities being created by advances in science, technology and information that were not possible in 1948. If we were to review the next 30 years of NHS history on the service’s centenary year, what current area of care do you think will develop to make the biggest change?

The area that needs to change the most is out-of-hospital care and the way that it integrates with in-hospital care so that the system is configured around the personalised needs of specific and unique patients. Technology is never an end in itself, but it can play a major role in facilitating this move from the dominance of in-hospital care to care that is centred on the patient – and which mostly tries to keep people out of hospital, but allowing them to benefit from expert medical care that comes to them rather than the other way round. This is the context within which the universal adoption of new and emerging technologies can have a major impact. That will create the single biggest change in the NHS of the future.

The NHS has a real and exciting opportunity to reinvent itself for the future and continue to be the leading healthcare model in the world. As well as the very specific technologies that will increasingly be introduced in to specific patient pathways using virtual reality or nano tech, the wider use of technology at the interface of the patient and our services will also provide us with opportunities that were not even available a decade ago. For example, we are already using technology so that more patients can be treated in their homes and I think that this will have increasing momentum in the next few decades. Not only will this see the evolution of the relationships we have with patients but it will also revolutionise how we care for and treat them as well. Not only will this see changes in how services are run but also impact in areas such as estates and facilities, training and education.

A few years ago you published a report on how our health and social care systems can be reformed to better align with the needs of today’s society. If anything, the crisis in our care system has magnified since then, so given the 70th anniversary of the NHS birthday, how can we ensure the two services do not remain ‘stuck in time’?

The key is to provide demand-side, patient-centred processes that ‘pull through’ reform. We need to break the cycle of supply-side, top-down initiatives that are well-intentioned but always run into the sand. They are re-launched year after year, the only change being that they are given new names (vanguards, new models of care, initiatives, pioneers, clinical commissioning groups, and so on).

These demand-side, patient centred mechanisms are: high quality information on outcomes that citizens can access and understand; ‘choice’ so that citizens can choose to use the services that provide the best outcomes; a commissioning system that encourages and incentivises providers to compete to deliver the best service to citizens; ‘personal budgets’ so that the taxpayers’ money follows the patient/citizen rather than propping up the outdated structures created in 1948.

This point about ‘personal budgets’ is vital – we need to put in place customised care packages for the most vulnerable in our society: those living with mental health conditions, frail elderly citizens, many of them living with co-morbidities and dementia, and, of course, those people with acute and chronic medical conditions. Health and social care workers do a fantastic job in this country. They are highly skilled and deeply committed, but their impact on improving the lives of the patients and citizens for whom they care diligently is severely constrained by a system that too often operates to confound them rather than support them.

In that Away from the past report you suggested that social care is being chronically under-funded, with any extra funding for the NHS being eradicated by extra demand caused by under-funded social care. To what extent must the NHS change this in the next few years in order to change that pressure in coming decades?

My brother, Professor Steve Smith, published our paper in the Health Service Journal in 2015, and the crisis in health and social care that we predicted then is playing out in reality. It is vital that the two systems – NHS healthcare and local authority social care – are merged immediately, and are underpinned by the patient-centred mechanisms outlined above. And it is clear that a number of other constraints to productive change are removed.

Besides more money (some of it raised by deterring abusive or inappropriate use of the system) we need to stop thinking of managers as overhead to be cut, but rather as vital agents in managing a highly complex system in the best interests of patients. And we need to have an education system that gives clinicians a well-defined path to becoming clinician managers. More broadly we need to invest in the workforce both by increasing the number of people in the service, reversing, for instance, the acute shortage of nurses, and by giving them the clinical skills to deliver high quality care in the context of a system that is professionally managed so that taxpayers’ money is spent effectively and so that the patient’s journey is as seamless and efficient as possible.

King’s is one of the most-publicised trusts to enter financial special measures. In what ways will the organisation use this as an opportunity to shape a better future and play a key role in delivering excellent and safe patient care for future generations?

Despite financial special measures, King’s has continued to deliver excellent care for our patients and continuing to do so remains our priority. I have always believed, and it is something that I say to staff whenever I can, that financial special measures presents King’s with an opportunity to further improve patient care and make King’s a blueprint for the rest of the NHS when it comes to operational efficiency and productivity.

Since December last year, we have asked questions like ‘How can we improve our systems and processes?’, ‘How can we improve collaboration between our services?’ and ‘How can we be as productive (especially in using our scarce human and capital resources) as possible?’. We asked these questions of staff across the trust at all levels and we are using their insight and experience to develop our future plans.

We are also working with NHSI and the team at Getting It Right First Time/Model Hospital, looking at specific services like Trauma and Orthopaedics, Ohpthalmology and Neuro-surgery. With their help, particularly Lord Patrick Carter and Tim Briggs, we are identifying ways to improve those services which we will then apply across the hospital. We still have some way to go but I am confident that King’s will emerge from financial special measures not only in a more stable and sustainable condition, but with a clear sense of direction and purpose.

The last 70 years has seen myriad innovations transform the way that care is delivered in the UK. Looking at King’s history, what trust innovation or change of behaviour stands out as the most impressive and why?

King’s serves a broad demographic and range of patient needs. We are one of London’s major trauma centres, we specialise in a variety of fields including blood cancers, liver transplantation, heart disease and neurosurgery and we offer high quality emergency and outpatient services in some of the most challenging parts of London. In all these services since the creation of the NHS 70 years ago, we have always sought to introduce innovations in care that will benefit our patients.

In the past few years alone we have introduced virtual reality into paediatrics, pioneered new brain surgeries that have reduced recovery time and undertaken long-term research that will benefit patients with certain types of cancer. In the two terrorist incidents last year (London Bridge and Westminster Bridge) and in the tragedy of Grenfell Tower, King’s world-class trauma and emergency services meant that we cared for a very large number of the victims, despite the events occurring in relatively distant parts of London.

The one constant through all of this, and this was especially evident during and after the terrorist attacks last year and since we entered financial special measures, is the continued dedication, commitment and bravery of the staff who make this hospital work. It is the staff who are to me, the most impressive thing about King’s. I make sure that I spend as much time as possible alongside the clinicians – either dressed in ‘scrubs’ observing brain or open-heart surgery, or visiting wards or doing a ‘shift’ with the London Ambulance Service as they come into our A&E department. They make King’s and the care we give to patients special and unique. I am very proud of them all.

In 2010, the Equity and excellence: Liberating the NHS white paper was published, emphasising the need to put patients at the heart of everything the NHS does. With the rate of advancement in technology continuing to gather pace, how can the health service make this aim a reality?

As I mentioned above, the increasing use of and integration of technology into public cand both in- and out-of-hospital health and social care is the most exciting part of the NHS’ future. However it can only work if access to that technology, be it in hospital or in the community, remains universally available to everyone. That should be, I believe, one of the guiding principles in terms of the NHS and any future relationship with technology. The challenge therefore is how does the NHS ensure that we keep pace with technology while at the same time ensure that no one is left behind? Naturally, some of this is about investment but it is also about collaboration and partnerships both within the NHS – for example King’s Health Partners which has extended to include an academic partner, as well as with external third party organisations, community providers and local authorities.

Previously executive chairman of Four Seasons Heath Care and chief executive of the General Healthcare Group, Ian Smith has an in-depth knowledge of the health care system and patient needs especially in terms of acute, psychiatric and elderly care. In 2015, Smith published ‘Away From the Past and to a Sustainable Future’ with his brother, Professor Stephen Smith, outlining necessary reforms in the UK health and social care system.

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